Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Thursday, September 18, 2008

In yesterday's post, I talked about how Ron Pies questioned the difference between depression and "proper sorrows of the soul"-- ah, Dr. Pies was quoting some dead monk-- and Lily mentioned that she was just diagnosed with Bipolar II. It got me thinking that we should say something about how a psychiatrist thinks about mood disorders. If you're a psychiatrist, you can go home now, today's blog post is not for you.

I'm going to start by saying that I'm typing this off the top of my head, I'm purposely not pulling out the DSM (Diagnostic Statistical Manual), I'm just rambling. I'm very good at rambling. So this is how I think about mood disorders and how I go about reaching a diagnosis.

In the course of the day, a person without a mood disorder generally feels "fine." People go through life with a fairly steady mood, not too good, not too bad. Sure, stuff effects mood, and it may vary some-- people feel transiently ecstatic about wonderful things happening, people feel sad about distressing things happen, and there's the unexplained 'bad hair day' also known as 'waking up on the wrong side of the bed.' Let's take it as a given that people have moods, they vary some, sometimes the reason is obvious, and they aren't generally extreme.

Mood itself is a good place to start. Mood variation alone is not enough to make a diagnosis of a mood disorder (weird, huh?) and someone who feels very sad, even a lot, who has no other symptoms of depression, isn't called depressed. So someone is trekking along just fine and then suddenly they start feeling down/sad/miserable and at the same time other symptoms emerge. These symptoms may include: changes in sleep, appetite, a decrease in the ability to feel pleasure, loss of energy, loss of interest, decreased sex drive, irritability, guilt, a feeling of being physically unwell, hopelessness, helplessness, thoughts that death might be welcome, or thoughts of suicide. People who have pain syndromes will have worse pain, people with Parkinson's Disease may have worsening of their movement disorder, people with dementia may have more trouble with their memories, food may seem tasteless, colors may look less bright. People's thoughts change-- these are the cognitive symptoms of depression-- with a tendency to see oneself in negative ways, to take on blame, to block or discount all positive feedback the world might give. You can't have just one symptom to be diagnosed with Major Depression, you have to have a few symptoms and they have to occur together, because mood disorders are 'syndromic' illnesses: they are defined by the co-occurring constellation of symptoms. The same person may have different symptoms during different episodes of depression, but generally episodes are discrete, and with or without treatment, they usually abate eventually.

There are some people who don't see their depressions as discrete episodes but feel they've been depressed for a very long time. Maybe they have Major Depression, but there is also a condition known as Dysthymia which is a chronic, low grade depression which lasts for years (--at least part of the day, most days, for at least 2 years, I think). This version of depression is not as striking as an episode of Major Depression-- the symptoms aren't as severe, abrupt, or debilitating and other people are often not as tuned in to the sufferer's distress.

That's the down side of mood.

Then there's the Up side of mood. Mania is the extreme up state, and the associated mood state is either elated/ecstatic or extremely irritable. Again, a simple shift in mood is not enough to diagnose an illness, there need to be some associated symptoms which occur at the same time as the mood elevation/extreme irritability. Manias include an increase in energy and a decrease in the need for sleep. The issue of Need for Sleep is important here: it's not normal to be awake and active for days at a time and not feel tired, this is much different than insomnia. People may have more ideas, they may have completely irrational ideas, judgment becomes impaired, thoughts may flow much faster, sometimes racing so fast that the patient can't keep up with them. Activity increases, speech may become fast and pressured. The person may feel very very good about themselves, very optimistic and positive, or believe they have special powers. There may be an increased interest in sex or religion, and people may spend lots of money on things they wouldn't normally spend on. Behavior may become impulsive and insight is often very impaired. The manic patient often resists the idea that they have an illness, and doesn't see how outrageous their behavior has become. They may hallucinate (see or hear or feel things that aren't there) or have delusions, particularly of grandeur, but sometimes of paranoia. Full blown mania is not subtle and often results in psychiatric hospitalization.

Anyone who has had even a single episode of Mania, ever, is diagnosed as having Bipolar Disorder, Type I, what used to be called Manic Depressive disorder. Do note that a person can be diagnoses as having Bipolar Disorder even if they've never (or Not Yet) had an episode of Major Depression. The fact is that it's extremely rare for someone to suffer an episode of mania and then live out life without ever having an episode of depression, that manias tend to recur (sometime after decades) and that it's not unusual for a person to have an episode of mania and then 'crash' into an episode of depression. Anti-depressants and steroids can precipitate an episode of mania and we still don't know if those manias have the same implication for lifelong diagnosis.

So mania isn't subtle, but there are people who have episodes of elevated mood states without the extreme symptoms. Maybe they have periods of time where their mood is better than the norm of fine/okay/good, and their energy is increased, and they are more productive or impulsive, and revved up than the usual even-keel. They may look good, feel good, live life a little more grandly. This may be subtle, and it's this state of elevation that is called Hypomania. This mood state may be hard to differentiate from a high-energy person, an anxious person, someone with Attention Deficit Disorder, or just the way that everyone wishes they could feel all the time. Hypomanias do not result in psychiatric hospitalizations and are not accompanied by extremes in behavior, hallucinations, or flagrant delusions. Hypomanias alone do not generally result in someone coming to psychiatric attention and patients present during episodes of Depression. This is Bipolar Disorder, Type II.

People with Bipolar Disorder, type II, generally spend much more time depressed than hypomanic, their depressions may be harder to stablize, and they often do better if a mood stabilizer is added to the treatment regimen.

If this isn't all confusing enough, there is a diagnosis called Cyclothymia, which means that a person's moods vary from hypomanic to mildly depressed, but none of the episodes of depression is severe enough to warrant a diagnosis of Major Depression. Psychiatrists don't use this diagnosis very much.

Okay, I'm going to add one more thought and then I'll shut up. Borderline Personality Disorder is a condition that includes "affective (=mood) instability" and the differentiation between a personality disorder and a mood disorder can be difficult even for experienced psychiatrists.

11
comments:

do you think there is such a thing as a "depressive personality disorder"? Does such a thing exist - and if so, does it fall within the spectrum to which Dinah was referring, or is it it's own entity entirely? I'm still unclear on the difference between DPD and Major depressive, because on the surface they seem to carry many of the same characteristics. So why the difference in terminology? and why has it been deemed "controversial"? or does the APA just have too much time on its hands right now?

Ok, so what if someone has been suffering from mood lability since the age of about ten. They get really really worked up every couple of months, and sometimes they feel justified but sometimes they feel just as mystified as the people around them. From the age of thirteen they fall into slumps a couple of times a year that cause them to muse about suicide and interfere with grades. But there are bursts of the person they could be: hope keeps coming back, bringing plans, optimism and confidence. Until it fizzles out again.

At thirty-three (by which time the depressive episodes have become longer and more severe, the uptimes have degenerated into irritability instead of hope, and the few in-between times are bleak) they read Listening to Prozac and get in on the neurotransmitter zeitgeist. They spend the next two years going from doctor to therapist to therapist again, all of whom bring out their Depression Inventory thingy and ask "How are you feeling today compared to six weeks ago?" Because the answer is "Um, not much different I guess, though it's hard to tell, and I hope you start asking some relevant questions because if you listened to my history you would know this wasn't relevant" it gets translated as "no change" on the little checkbox that doesn't have a space for paragraphs or essays or comments. And doctors and therapists all agree that the person cannot possibly have a mood disorder because the checklist says so, and see no need to refer to a psychiatrist.

In your little vignette, "Someone is trekking along just fine and then suddenly... ." In my experience, psychiatrists don't absolutely need someone to be trekking along just fine all their lives until something inexplicably and dramatically changed six weeks ago. They are able to figure out that something is out of kilter without that baseline.

Therapists and non-psychiatrist MDs tend to cling to their inventory scales and miss people who don't have that made-for-TV history. (In my experience.)

What does the psychiatrist look for or see that enables them to see Bipolar II where other professionals see "I don't know what she's on about, but no change in the last six weeks or even in six months, so clearly she's not depressed and probably has a personality disorder and I don't have a clue how to deal with that"?

Alison-- this is why I spend 2 hours on an evaluation and don't give people checklists. I still don't get it right all the time. And I included dysthymia and the concept of very long term depressions (a subset of people don't have an abrupt onset but have many symptoms and say they've been depressed for as long as they can remember) because not everyone can point to a calendar and pick the day-- also, I didn't mention the concept of Rapid Cycling in Bipolar Disorder, but this also makes the checklist thing difficult. My "6 weeks" example was because the most common presentation of depression is a discrete (abrupt or gradual) onset of symptoms, but there is no magic to 6 weeks and I've never heard of this as a cutoff for anything. Many depressions last months, so I could have just as easily said "treking along until 6 months ago"....Dinah

Once a person is diagnosed as, say Bipolar II, do they keep that designation for the rest of their lives?

For example, suppose someone is clearly bipolar through their late teens, twenties, and thirties, and has to take a mood stabilizer to stay on an even keel.

Then this person hits middle age, and suddenly there are few signs of depression (on meds) and no more signs of hypomania for years, even into the start of menopause. So the person goes off the mood stabilizer, and everything stays fine.

Would that person still be considered bipolar? Or is it possible to be downgraded to "just" MDD with anxiety?

BTW, I'm asking for a friend. :)

Seriously, I know you can't give personal medical advice and that this "person" needs to speak to his or her own psychiatrist.

I was just wondering --generally-- if the phenomenon ever occurs; do longstanding patterns tend to be enduring, or can they change dramatically over time?

bipolar 1. assessed and reassessed. no one ever asked me about a 6 week time frame. they all dug way back. they also asked how many times in the past year i had felt x y or z or engaged in x y or z behavior.

A very, very helpful post. Answered a couple of questions I'd had for a while. But this last bit here...

Okay, I'm going to add one more thought and then I'll shut up. Borderline Personality Disorder is a condition that includes "affective (=mood) instability" and the differentiation between a personality disorder and a mood disorder can be difficult even for experienced psychiatrists.

...raised another question which is: Is there any one or two key symptoms/behaviors that clearly differentiate Borderline Personality Disorder from any one of the mood disorders?

I'll be honest: I have a personal interest in the answer. I've been in between BP II, Depression and BPD for years and I can't get a definitive diagnosis from the mental health professionals I'm seeing now.